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Berwal D, Quintero A, Telkes I, DiMarzio M, Harland T, Paniccioli S, Dalfino J, Iyassu Y, McLaughlin BL, Pilitsis JG. Improved Selectivity in Eliciting Evoked Electromyography Responses With High-Resolution Spinal Cord Stimulation. Neurosurgery 2024:00006123-990000000-01063. [PMID: 38376181 DOI: 10.1227/neu.0000000000002878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/29/2023] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND AND OBJECTIVES As spinal cord stimulation (SCS) offers a therapy for increasing numbers of patients with chronic pain and spinal cord injury, it becomes increasingly important to better understand its somatotopy. In this prospective study, we investigate whether high-resolution SCS (HR-SCS) offers improved selectivity assessed through elicitation of evoked electromyography (EMG) responses as compared with commercial paddle leads. METHODS Vertical tripole configurations were used to elicit EMG responses in both types of paddles placed for standard-of-care indications between T6 and T10. In HR-SCS, evoked EMG responses in lower extremity/abdominal muscle groups were monitored at 6 to 8 mediolateral sites. All commercial paddle columns were tested. Percentage change in the maximum root mean square value was calculated at a group level. Heat maps were generated to identify responders for each muscle group. Responders were considered patients who had a >50% change in root mean square over baseline. RESULTS We demonstrated significantly greater motor responses across medial and lateral contacts and greater responder rates consistently at the T6 and T9 levels with HR-SCS as compared with commercial paddles in 18 patients. Distal muscle groups (gastrocnemius and tibialis anterior) and proximal muscle groups (biceps femoris and quadriceps) were selectively activated at both levels. CONCLUSION We demonstrate that HR-SCS has greater selectivity in eliciting evoked EMG responses in an intraoperative setting. HR-SCS offers recruitment of muscle groups at lateral contacts concurrently with medial contacts. We provide data that HR-SCS may provide higher spatial resolution, which has the potential to allow for personalization of care and treatment of pain syndromes/symptoms which to date have not been effectively treated.
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Affiliation(s)
- Deepak Berwal
- Department of Clinical Neurosciences, Florida Atlantic University, Boca Raton, Florida, USA
| | - Alejandra Quintero
- Department of Clinical Neurosciences, Florida Atlantic University, Boca Raton, Florida, USA
| | - Ilknur Telkes
- Department of Biomedical Sciences, Florida Atlantic University, Boca Raton, Florida, USA
| | - Marisa DiMarzio
- Department of Clinical Neurosciences, Florida Atlantic University, Boca Raton, Florida, USA
| | - Tessa Harland
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | | | - John Dalfino
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | | | | | - Julie G Pilitsis
- Department of Clinical Neurosciences, Florida Atlantic University, Boca Raton, Florida, USA
- Department of Neurosurgery, University of Arizona- Tucson, Tucson, Arizona, USA
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Prabhala T, Figueroa F, Harland T, Nabage MN, Pilitsis JG. The Use of Salvage Procedures for Wound Complications in Neuromodulation. World Neurosurg 2023; 171:e596-e604. [PMID: 36529435 DOI: 10.1016/j.wneu.2022.12.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Wound complications are a prevalent concern for neuromodulation procedures. While removal of the device was recommended, attempts to salvage expensive hardware have become commonplace. We examine our management in wound issues to aid in providing guidance for these situations. METHODS We identified 40 patients over an 8-year period in a large neuromodulation practice, who underwent washout or partial salvage of hardware. We examined the efficacy of washout and partial explants on the ability to salvage the implants. Covariates including age, sex, body mass index, smoking status, anticoagulation, and device type were considered. RESULTS There were 29 washouts and 10 partial hardware removal cases. Washouts were successful in 15/29 cases (51.7%), partial hardware removal was successful in 2/10 cases (20%), and removal with replacement was not successful (0 of 1). Washouts tended to be more successful than partial removal procedures (P = 0.08). In cases of successful washout, the average duration between infectious symptoms and washout was 7.27 ± 2.19 days. None of the demographic variables were associated with increased likelihood of washout failure. CONCLUSIONS Our results demonstrate a higher rate of washout failure in those who underwent partial device removal and in the presence of purulence at the surgical site. Further investigation must be conducted to determine the instances in which hardware removal is indicated to prevent failure or removal due to infection. Identification of these parameters will optimize therapeutic benefit and long-term financial impact.
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Affiliation(s)
- Tarun Prabhala
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Fernando Figueroa
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Tessa Harland
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Melisande N Nabage
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Julie G Pilitsis
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA; Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA.
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Johansen PM, Trujillo FA, Hagerty V, Harland T, Davis G, Pilitsis JG. Establishing Minimal Clinically Important Difference in Sleep Outcomes after Spinal Cord Stimulation in Patients with Chronic Pain Disorders. Stereotact Funct Neurosurg 2023; 101:41-46. [PMID: 36574755 DOI: 10.1159/000527257] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/16/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION As one of the most common medical conditions for which patients seek medical care, chronic pain can be debilitating. The relationship between chronic pain and sleep is thought to be bidirectional, suggesting that treatment of one can be beneficial to the other. There is mounting evidence that spinal cord stimulation (SCS) improves aspects of sleep. How meaningful that is to patients' lives has not been ascertained. OBJECTIVE The aim of the current study was to further elucidate the effect of SCS on sleep by examining the relationship between pain outcome measures with the insomnia severity index (ISI) and to establish the minimally clinical important difference (MCID), which is defined as the smallest noticeable change that an individual perceives as clinically significant. MATERIALS AND METHODS We prospectively collected ISI, Epworth sleepiness scale (ESS), Numerical Rating Scale, McGill Pain Questionnaire-Short Form, Oswestry Disability Index, Beck Depression Inventory, and Pain Catastrophizing Scale data both pre- and postoperatively for chronic pain patients who underwent SCS placement and had long-term outcomes. The ISI is a well-studied questionnaire used to assess an individual's level of insomnia. RESULTS We correlated the ESS and ISI with pain outcome measures in sixty-four patients at a mean follow-up of 9.8 ± 2.9 months. The ISI showed correlations with disability as measured through the Oswestry Disability Index (p = 0.014) and depression as measured through the Beck Depression Inventory (p = 0.024). MCID values for the ISI were calculated using both anchor- and distribution-based methods. The minimal detectable change method resulted in an MCID of 2.4 points, standard error of measurement resulted in an MCID of 2.6 points, and the change difference resulted in an MCID of 2.45. The receiver operating characteristic method yielded an MCID of 0.5-point change with an area under the curve of 0.61. CONCLUSION This study successfully established MCID ranges for the ISI outcome measure to help gauge improvement in insomnia after SCS. The ISI has ample evidence of its validity in assessment of insomnia, and MCID values of 2.4-2.6 correlate with improvement in disability and depression in our patients.
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Affiliation(s)
- Phillip M Johansen
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Frank A Trujillo
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Vivian Hagerty
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Tessa Harland
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Gregory Davis
- Department of Neurosurgery, Albany Medical Center, Albany, New York, USA
| | - Julie G Pilitsis
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
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Harland T, Gillogly M, Khazen O, Gajjar AA, Nabage M, Trujillo F, DiMarzio M, Pilitsis JG. A Pilot Study Comparing Algorithmic Adaptive Conventional Stimulation with High-Dose Stimulation in Chronic Pain Patients. World Neurosurg 2022; 167:e871-e876. [PMID: 36031115 DOI: 10.1016/j.wneu.2022.08.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/21/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Spinal cord stimulation is an effective method of treatment for chronic pain. We previously showed that programming using accelerometry was advantageous for paresthesia-based stimulation. However, programming can be labor intensive. OBJECTIVE Here we focus on standardized programming for both accelerometer-based paresthesia-induced programming (termed "shuffle") and high-dose (HD) subthreshold programming with stimulation delivered over the T9-10 interspace. METHODS In this prospective cross-over study, patients received 4 weeks of shuffle programming and 4 weeks of HD programming in a randomized order. In both intervals, contacts overlying T9-10 were programmed. Pain scales with measurements of activity and sleep were collected at the end of each study arm and compared with preoperative baseline scores. RESULTS Twelve patients were enrolled, with 10 patients completing this study. Compared with baseline, during the HD study period, significant improvements were seen in worst pain of week (P = 0.03) and current pain (P = 0.04) as rated on Numeric Rating Scale scores and walking on the Activity Test (P = 0.012). No difference was seen from baseline compared with shuffle stimulation or in shuffle stimulation compared with HD stimulation. CONCLUSION In this pilot study, we demonstrated that HD stimulation at T9-10 is superior to algorithmic programming of paresthesia-based stimulation. These results compared with our previous work with shuffle suggest that paresthesia-based stimulation may necessitate stimulation of additional contact locations and additional programming to optimize. This algorithmic programming of paresthesia-based stimulation continues to warrant exploration.
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Affiliation(s)
- Tessa Harland
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Michael Gillogly
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Olga Khazen
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Avi A Gajjar
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Melisande Nabage
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Frank Trujillo
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Marisa DiMarzio
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Julie G Pilitsis
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA; Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA.
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Topp G, Harland T, Spurgas M, Rock A, Pilitsis JG. Techniques for Safe Removal of Spinal Cord Stimulation Paddle Leads. Oper Neurosurg (Hagerstown) 2022; 23:e348-e352. [DOI: 10.1227/ons.0000000000000388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 06/12/2022] [Indexed: 11/06/2022] Open
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Hadanny A, Harland T, Khazen O, DiMarzio M, Marchese A, Telkes I, Sukul V, Pilitsis JG. Development of Machine Learning-Based Models to Predict Treatment Response to Spinal Cord Stimulation. Neurosurgery 2022; 90:523-532. [PMID: 35179133 PMCID: PMC9514733 DOI: 10.1227/neu.0000000000001855] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 11/03/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Despite spinal cord stimulation's (SCS) proven efficacy, failure rates are high with no clear understanding of which patients benefit long term. Currently, patient selection for SCS is based on the subjective experience of the implanting physician. OBJECTIVE To develop machine learning (ML)-based predictive models of long-term SCS response. METHODS A combined unsupervised (clustering) and supervised (classification) ML technique was applied on a prospectively collected cohort of 151 patients, which included 31 features. Clusters identified using unsupervised K-means clustering were fitted with individualized predictive models of logistic regression, random forest, and XGBoost. RESULTS Two distinct clusters were found, and patients in the cohorts significantly differed in age, duration of chronic pain, preoperative numeric rating scale, and preoperative pain catastrophizing scale scores. Using the 10 most influential features, logistic regression predictive models with a nested cross-validation demonstrated the highest overall performance with the area under the curve of 0.757 and 0.708 for each respective cluster. CONCLUSION This combined unsupervised-supervised learning approach yielded high predictive performance, suggesting that advanced ML-derived approaches have potential to be used as a functional clinical tool to improve long-term SCS outcomes. Further studies are needed for optimization and external validation of these models.
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Affiliation(s)
- Amir Hadanny
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA;
| | - Tessa Harland
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA;
| | - Olga Khazen
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Marisa DiMarzio
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Anthony Marchese
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Ilknur Telkes
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Vishad Sukul
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA;
| | - Julie G. Pilitsis
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA;
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
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Harland T, Hadanny A, Pilitsis JG. Machine Learning and Pain Outcomes. Neurosurg Clin N Am 2022; 33:351-358. [DOI: 10.1016/j.nec.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Harland T, Prabhala T, Nardolillo A, Boulos AS, Adamo M, Dalfino JC, Paul A, Entezami P. 476 Does Anticoagulation or Antiplatelet Therapy Increase Risk of Traumatic Subarachnoid Hemorrhage Progression? Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Harland T, Zbrzeski C, DiMarzio MD, Khazen O, Staudt M, Pilitsis JG. Craniofacial Peripheral Nerve Stimulation. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ung TH, Yang M, Wang M, Harland T, Lillehei KO. Benefit of Intracystic Bleomycin for Symptomatic Recurrent Rathke Cleft Cyst. Oper Neurosurg (Hagerstown) 2019; 17:268-272. [PMID: 30445570 DOI: 10.1093/ons/opy361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 10/20/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Management of recurrent Rathke cleft cysts (RCC) is problematic. The mainstay of treatment has been reoperation with cyst drainage. Radical cyst resection, although effective, results in a high incidence of diabetes insipidus. Several case reports suggest a potential benefit to radiation therapy or the use of intracystic bleomycin. The intracystic application of bleomycin is known to be beneficial in the treatment of cystic craniopharyngioma; however, its usefulness in the treatment of recurrent RCC has yet to be proven. OBJECTIVE To present our 6-yr experience using intracystic bleomycin for recurrent RCC. METHODS We performed a retrospective chart review of patients with RCC who underwent surgical resection between January 2010 and May 2016 by a single surgeon. Specific attention was paid to patients with recurrent RCC. RESULTS Of the 59 patients operated on for RCC during this 6-yr interval, 6 patients with symptomatic recurrent RCC were identified and received intracystic bleomycin at the time of reoperation. To date, no symptomatic cyst recurrence has been documented in the patients receiving bleomycin (mean = 38.8 mo, range 21.2-79.8 mo). CONCLUSION The use of intracystic bleomycin appears to be a safe and potentially effective treatment option in patients with recurrent RCC. Additional studies with longer follow-up are needed to further define the role of bleomycin in recurrent RCC.
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Affiliation(s)
- Timothy H Ung
- School of Medicine, University of Colorado, Aurora, Colorado.,Department of Neurosurgery, University of Colorado, Aurora, Colorado
| | - Michael Yang
- School of Medicine, University of Colorado, Aurora, Colorado
| | - Mary Wang
- Department of Neurosurgery, University of Colorado, Aurora, Colorado
| | - Tessa Harland
- School of Medicine, University of Colorado, Aurora, Colorado
| | - Kevin O Lillehei
- School of Medicine, University of Colorado, Aurora, Colorado.,Department of Neurosurgery, University of Colorado, Aurora, Colorado
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Reyes LD, Harland T, Reep RL, Sherwood CC, Jacobs B. Golgi Analysis of Neuron Morphology in the Presumptive Somatosensory Cortex and Visual Cortex of the Florida Manatee (Trichechus manatus latirostris). Brain Behav Evol 2016; 87:105-16. [PMID: 27166161 DOI: 10.1159/000445495] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 03/15/2016] [Indexed: 11/19/2022]
Abstract
The current study investigates neuron morphology in presumptive primary somatosensory (S1) and primary visual (V1) cortices of the Florida manatee (Trichechus manatus latirostris) as revealed by Golgi impregnation. Sirenians, including manatees, have an aquatic lifestyle, a large body size, and a relatively large lissencephalic brain. The present study examines neuron morphology in 3 cortical areas: in S1, dorsolateral cortex area 1 (DL1) and cluster cortex area 2 (CL2) and in V1, dorsolateral cortex area 4 (DL4). Neurons exhibited a variety of morphological types, with pyramidal neurons being the most common. The large variety of neuron types present in the manatee cortex was comparable to that seen in other eutherian mammals, except for rodents and primates, where pyramid-shaped neurons predominate. A comparison between pyramidal neurons in S1 and V1 indicated relatively greater dendritic branching in S1. Across all 3 areas, the dendritic arborization pattern of pyramidal neurons was also similar to that observed previously in the afrotherian rock hyrax, cetartiodactyls, opossums, and echidnas but did not resemble the widely bifurcated dendrites seen in the large-brained African elephant. Despite adaptations for an aquatic environment, manatees did not share specific neuron types such as tritufted and star-like neurons that have been found in cetaceans. Manatees exhibit an evolutionarily primitive pattern of cortical neuron morphology shared with most other mammals and do not appear to have neuronal specializations for an aquatic niche.
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Affiliation(s)
- Laura D Reyes
- Department of Anthropology and Center for the Advanced Study of Human Paleobiology, The George Washington University, Washington, D.C., USA
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Janssen J, Hale L, Mirfin-Veitch B, Harland T. Are physiotherapists ready to conduct research as part of their daily practice? Physiotherapy 2015. [DOI: 10.1016/j.physio.2015.03.3510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
This paper gives an account of a small-scale longitudinal study that examined changes in conceptions and approaches to learning as 14 students experience a problem-based learning (PBL) curriculum for the first time. The course in oral biology aimed to encourage conceptual understanding of the topic and improve student learning through its PBL curriculum and assessment method. Those who entered the course with a surface approach and fragmented conception of learning left with a deep-learning approach, cohesive conception and quality learning outcomes. There were no observable changes in the students who started the course with a deep-learning approach and cohesive conception, except for two who reported surface approaches and fragmented conceptions at the end. These two students also achieved the lowest examination scores. To help explain these findings we examine the wider context for student learning including student motivation.
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Affiliation(s)
- J Kieser
- Department of Oral Sciences, University of Otago, Dunedin, New Zealand.
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